Quality Analyst and Improvement Specialist
Department: Quality Management
Job Type: Full Time
Job Class: Non-Union
Work Shift: Day/Evening with Variable Start Time
Work Days: 8.5 day
Date Posted: 01/07/2020
Requisition Number: hrq-86529
Completes an organized medical record review and data abstraction. Analyzes and use this and other data to facilitate clinical quality improvement projects. Responsible for accurate and timely entry of data into registries and other databases.
Data Collection and Reporting: Completes an organized medical record review and data abstraction as required for CHA reporting. Is flexible with work hours in order meet deadlines and provide maximum abstraction productivity. Attends weekly Morbidity & Mortality conferences to ensure reliable data collection. Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program through Inter-Rater Reliability (IRR) testing. Researches, verifies and validates medical record documentation, including review of tests and reports, to record and report accurate information to external sources. Maximally utilizes all CHA data sources including hospital medical record, Meditech, and EPIC Identifies streamlining and process improvement opportunities in the data collection process. Reviews data reports in order to identify inconsistencies. Communicates discrepancies/concerns to Director Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the program. Utilizes all necessary software applications for data collection and analysis. Responsible for the accurate and timely entry of data into the NSQIP program's database and meets the caseload accrual requirement protocol. Reviews data for submission to NDNQI Reviews weekly site accrual report on the database and responds to accrual report alerts. Recommend corrective action to maintain integrity of coding and medical record documentation to ensure compliance. Reviews protocols for compliance with established databases, laws and regulations, policies and procedures
Works Effectively with Leadership, Staff, Patient and Families: Establishes effective working relationships with members of the CHA community, especially staff in the Surgery, Medicine, Nursing, Medical Records, Information Systems and Quality and Patient Safety Departments whose support is necessary for the management and success of improvement projects. Contacts patients and/or families via telephone and/or written communications postoperatively for identifying possible occurrences associated with surgical procedures performed at the hospital. Serves as an educational resource on the ACS NSQIP for internal and external audiences by developing educational material and delivering presentations. Works collaboratively to provide information internally and externally to appropriate departments as needed
Uses data collected to facilitate change: Use PDSA and other quality improvement methodologies to improve patient safety and care Improve access and efficiency
Other responsibilities: Meets monthly with Leadership and staff to review data collection and feedback from NSQI, NDNQI and databases and registries Remains current regarding changes in regulatory requirements as related to pertinent data collection Performs other duties as needed and/or requested in order to enhance and maximize departmental resources
Education/Training: Bachelor's degree in Health Care or other related fields. Licensure: RN, LPN, respiratory therapy, pharmacy a plus Certifications: CPHQ preferred, Must successfully complete ACS NSQIP SCR training and certification after hire. Coding certification a plus Work Experience: 3-5 years clinical experience in a hospital or other health care environment is required.